Q&A with Dr. L. Gary Hart, Director of the Center for Rural Health at the University of North Dakota School of Medicine and Health Sciences

By Laura Trude, HWIC Information Specialist

The Advisory Committee on Interdisciplinary, Community-Based Linkages recently released a report on rural health workforce issues, originally penned in 2008, which emphasizes that chronic rural health workforce shortages are likely to worsen in coming years. One of the authors for the report, Dr. Gary Hart, has been involved in health workforce research for approximately twenty-five years. He shares what it would take to create a future without shortages and maldistribution of health care providers in rural areas, based on the knowledge he’s gained researching health workforce issues.

Since this report was developed, a number of the recommendations you and your co-authors make have been implemented: family medicine residency programs are providing more training in community health centers, the National Health Service Corps was expanded with the American Recovery and Reinvestment Act (ARRA) funding, and the National Commission on the Health Workforce will help coordinate federal and state workforce activities. What still needs to be done?

The good news is that many of the proposed ideas have come to fruition or are coming to fruition, but much still needs to be done. The National Commission now exists, they put people in it, but there’s no money so they can actually meet.

There needs to be an increase in the number of health professionals who are trained to provide care in rural areas. This has to do with many things, like with what happens with federal graduate medical education (GME) money. Does it actually go to rural communities to help support those residencies and other activities in those places? Historically little has been passed on to rural training sites.

The report also talks about multidisciplinary training, getting health professionals to work together in training so that they can do so when they start practicing. There have been strides in this area, but there’s still much to be done.

The report says we need to train more people in rural areas. There have been a number of studies done, one of which I did a few years ago that examines rural family physician training in the nation. While only a little more than 7% of the family medicine residency training takes place in rural places, 20-25% of the population lives there, so that is an obvious issue to target. If we want to increase the providers who are willing to go to rural areas to practice, we’ve got to increase that percentage.

For all of the lip service and all of the programs to get physicians to practice in rural areas, the medical schools across the country and many of the other schools of other professions have been very hesitant to get out of big cities. That’s understandable but even of the 7% being trained in rural areas, almost all of it is in big rural, places with a 30-45,000 population. The number of family medicine residents who are actually trained in small, rural areas is less than one percent. There’s just not enough training taking place in those kinds of places.

One way or another, you want to create a pipeline that gets rural kids into health professions schools. That’s the single biggest predictor of practicing in rural areas – it’s not the only one, but it’s the biggest one. And then you’ve really got to make good programs so you don’t end up having them so tied into urban areas where they get a lot of their training that they won’t go back or that they pick professions that aren’t needed in rural areas. For example, if you’re going to be a thoracic surgeon, you’re not going to be a rural doc. We’ve got thoracic surgeons and we’ve got other specialists but we need to get more rural, primary care providers and nurses and physician assistants and all of the other provider types like x-ray technicians for the rural hospitals. It isn’t just physicians, although I keep speaking about physicians to emphasize them because it’s one of the more important professions where we have severe shortages and maldistribution, but they all matter.

It’s not just producing docs that you can either coerce or you can get to come to some place because you dangle money in front of them. We want rural providers who are efficient, respective, and culturally competent to practice in rural settings – it matters in Indian country and in rural communities. How many can picture having a Manhattan-raised kid practicing in Cando, North Dakota? It’s just not likely to happen, not that it can’t, but it’s not likely to happen.

A while back I was involved in a study where we looked at who produces rural docs in this country by medical school. As I recollect, twenty-five medical schools produced 60 or 70% of all the rural docs in this country. Fifty of the schools in aggregate produced only 2%. The bottom 10 schools in a decade didn’t produce one single rural doc. This seems really difficult to do unless you’re trying to do it. Meanwhile, the schools like those in North Dakota, Washington, Minnesota, Missouri, and North Carolina produce substantial numbers of rural docs – we still don’t have as many as we need, but they produce a lot.

If you’re going to have federal programs and you’re going to invest money to train rural docs, historically the way the federal government has addressed this is to give the schools that are not doing very well a lot of money so they can try to do better. Johns Hopkins manages to get significant National Health Service Corps funds that way, but I think it’s time we start rewarding and expanding the programs that actually produce rural docs and that we really emphasize those places so that we are rewarding success instead of rewarding not doing well.

There are certainly multi-disciplinary interactions we don’t yet understand: what’s an optimal practice and what’s an optimal mix of providers in those practices. On the other hand, most of what it would take to get enough providers in rural America we know. We just know it and don’t do it.

What would it take to create a future without shortages of health care providers in rural areas?

You need to have more kids who came from or are connected to rural areas and need to figure out ways of identifying them. We need to make changes to the curriculum so that the family physicians and nurses and physician assistants, whatever you’re talking about, will feel comfortable being in a place where they are responsible for more and often have less technology and specialty backup. If we train them to do what people do in cities, they will feel very uncomfortable out there in rural areas.

Telehealth can help with that. The other day, I heard about a doctor who was dealing with this patient who had been in a car accident. He had a couple of emergency room specialists giving him advice using telehealth and they lost the patient. The doc said, “When that happens and I don’t have that connection, I spend a week being awake at night, worrying, is there something I could have done? In this case, I know we did the best we could do. I still feel bad about losing the patient, but I don’t feel like it was just me who did that.”

Another one is the financial support for the residencies themselves. We should put more money into supporting residencies in rural hospitals. You’ve got to change the rules or the curriculum so it’s okay to have residencies in a small volume place with few residents.

Finally, there have to be incentives for the rural providers. We not only help train and guide rural providers, but we train rural community people and, when we’re good, we train them how to recruit and keep providers and integrate them into their communities – and all that’s all as important as training the providers. But if a rural community doesn’t fulfill all three of these following needs, it doesn’t matter what else we or they do. The docs will not stay or they won’t come if: first, the rural community has to be a place where it’s fiscally rewarding; it can’t short-change them, and expect them to make less than everywhere else – and work more; second, it has to be professionally acceptable – that is, the docs they’re working with, and the clinic itself and how it looks and the professional side of things and their ability to go get continuing medical education, all that has to be acceptable to them, they can’t feel second-class or eventually many of them will leave; and third, they need to find the community socially acceptable and enjoyable — the community itself needs to have good schools and they need to find themselves being accepted into the community, among other things.

There are lots of stories of people showing up and not feeling comfortable. When I was in Washington, there was a time when several of the people who were training to be physician assistants were Alaska natives. They would land in the airport and take a taxi downtown to get to the university and then turn around, take another taxi back to the airport and go home either immediately or within a few days or weeks. They had never seen a building more than three stories high. Interesting how the university environment was so different from where they needed to serve, way out in the middle of Alaska. That is just like going from 1640 to 2010 in an airplane ride. They’ve actually expanded the programs up in Alaska and are trying to do a lot more with that and have adapted how they integrate these students into the environments. You’ve got to understand how going to New York City, Seattle, and Phoenix and those types of places is tough for somebody rural, and I mean really rural, especially those who have always been very isolated.

What do you think it will take at the policy or organizational level to get people to actually do these things?

We need to coordinate health workforce policy. I go to an international health workforce meeting every year as a U.S. delegate. We are the only country in attendance at the conference that has no federal workforce planning people there. We have no federal workforce people because we haven’t coordinated things in the country. Canada does, Australia does, the UK does, New Zealand does, all these countries do, but we don’t. But there’s movement, having that National Commission is a step in that direction. They aren’t the czars of it all, but they can help coordinate it, though as of now the Commission is not funded through the health care reform legislation.

The Accountable Care Act, as it currently sits as law, is filled with clauses that deal with health workforce. Many aren’t high-cost items, but there are many of them in there. If those clauses or a portion of them were implemented, they would change things more than anything I’ve seen during the decades I’ve been involved in rural health workforce.

Of course, all this depends on how health reform morphs. It’s not going to go away, but it’s not going to stay the same. There are things that will come out and things that won’t. Most of these issues I’m talking about are really bi-partisan in content, but the overriding issue is going to be the nature of budget reductions. We’ve got to spend some money and that’s an issue with the Congress, but there’s not going to be much argument about whether or not it’s a good thing to do. It’s a question of whether or not we are going to pay for it and whether cuts are going to be surgical or performed with a sledge hammer. As I indicated, much of the change we need in the health workforce arena is low cost or just a matter of using resources more wisely.

You addressed the federal policy level. What about at a more regional level, the medical schools, the health professions schools, what do you think it will take for them to implement these sorts of policies?

In many ways, health profession schools are driven by state legislatures. States are in trouble all over the country. In some states, like where I was not long ago, in Arizona, they cut all of the GME money altogether. It didn’t matter whether it was rural or urban; it was going to hurt everybody. That’s a problem if you are going to train more rural family physicians.

Expanding coverage of insurance means we need more primary care providers. What’s going to happen to rural providers if we’re going to try to induce people to come to rural areas but demand is incredibly high in urban places? It’s going to make it that much harder to recruit them unless we grow and nurture our own from rural areas.

The medical schools are driven by the state legislature in terms of the medical school part, but then they and hospitals run residencies and are involved in networks of residencies, and those are driven by federal and private dollars.

What are the gaps in health workforce research?

There are a lot of things we don’t know very much about, and there are many others we assume are true that haven’t been verified by research.

We still don’t know whether it’s more cost-effective to use multiple types of health care providers or what the best configuration is: how many physicians, PAs, NPs, nurses, therapists, etc. we should really be using. A lot of research still needs to be done on that.

We’ve found that telehealth works great in some situations for primary care providers, but there’s a lot we still need to evaluate about what’s effective and what’s not effective. It certainly helps with specialty care but if a small rural town already has a shortage of primary care providers, telehealth will not solve this problem.

Another trend we’ve been seeing for a while is that more women are going into medicine. That’s a good thing, there’s no one who will argue that is not a good thing. But a lower percentage of women physicians have traditionally moved to small and remote rural areas to practice. There are a lot of factors that go into that, but it brings up the significant question — can we create programs in medical schools that will increase the percentage of female physician graduates who practice in small and remote rural areas?

Please note that the views expressed in this article are the opinions of the interviewee and do not reflect the official policies, positions, or opinions of the Health Workforce Information Center or its funder.